Myth Buster: Get Ahead of MPFS 2017 Inspection of 0-Day Global Codes With Mod 25

Tue, Aug 23, 2016


2017 MPFS 0 day global modifier 25

A previous post about the 2017 physician fee schedule mentioned that the proposed rule lists 83 services with 0-day globals to review because of the large number of same-day E/Ms being reported with those codes.

If that news got your codey-sense tingling, defeat your audit fears by busting these troublemaking myths.

But first: Speaking of fees, have you heard about the changes planned for the Multiple Procedure Payment Reduction (MPPR) that Medicare applies to the professional component (PC) of certain diagnostic imaging services? Currently, the MPPR results in a 25 percent reduction in the PC payment for additional imaging services beyond the first provided by the same physician to the same patient in the same session. The change, effective Jan. 1, 2017, will adjust that reduction from 25 percent to 5 percent. That means you’ll get paid 95 percent instead of 75 percent!

Now back to the main attraction.

Myth 1: 0-Day Global Period Is the Same as No Global Period

On the Medicare Physician Fee Schedule (MPFS), you can check a code’s global period indicator. There are various options, but here we’re concerned with distinguishing XXX from 000.

An indicator of XXX means the global concept does not apply. Don’t confuse XXX with 000, the indicator for a 0-day postop period. You will see 000 assigned typically to endoscopies and some minor procedures.

Key point: A 0-day global means that there is no pre-operative period and no post-operative days, but Medicare typically does not separately reimburse a visit on the same day as the procedure.

Myth 2: The Decision Visit Is Always Separately Reportable

At some point you may have learned that Medicare does not include the initial evaluation to determine the need for surgery in the global surgical package.

But it’s crucial to note that rule applies to only major surgical procedures, meaning those with a 90-day global. “The initial evaluation is always included in the allowance for a minor surgical procedure,” according to the Medicare Claims Processing Manual (MCPM), Chap. 12, Section 40.1.B.

Bottom line: Report an evaluation and management service by the surgeon on the day of the minor surgery or endoscopy only if the E/M is a significant, separately identifiable service. A beneficiary medical history does not count. The MCPM offers the example of a visit for a full neurological exam on a patient requiring scalp sutures after a head injury.

Append CPT® modifier 25 to the E/M code, such as CPT® code 99213, to indicate the service was above and beyond the usual pre- and postop care.

Myth 3: The 83 Codes in the MPFS Are the Only Ones to Watch

The proposed Medicare fee schedule has called out 83 codes that have high rates of same-day E/Ms. Tip: Law firm Womble Carlyle Sandridge & Rice has posted a list of the codes here.

But don’t spend all your energy watching just these codes. You should follow the rules about when to report a separate E/M any time you report a code with a 0-day global.

Ethical coding is all about reporting the services performed and documented, guided by the official rules of reporting. Inappropriately unbundling an E/M code from a procedure is double-dipping for payment because CMS includes payment for the typical pre- and postop services in the payment for the 0-day procedure code. Keeping tabs on the rules keeps your claims clean and prevents having to refund payers in the future.

How About You?

What are your tips for using modifier 25 correctly?

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3 Things Orthopedic Coders Need to Know About ICD-10 2017

Fri, Aug 19, 2016


cervical spine orthopedic ICD10 2017

Orthopedic coders: If you claim that you get hit particularly hard by ICD-10, you may have a point!

When ICD-10 introduced nearly 200 codes to replace 714.0 (Rheumatoid arthritis) in 2015, you earned the right to take a breather before moving on to learning the seven different seventh character options that may apply to fractures.

And now it’s time to prepare for the changes coming to orthopedic diagnoses in the ICD-10-CM 2017 code set, which will go into effect Oct. 1, 2016. You can start your prep work with these three helpful hints.

1. Nail Down Atypical Femoral Fracture Terminology

New subcategory M84.75- (Atypical femoral fracture) has people asking what exactly an atypical fracture is. The ICD-10 Tabular doesn’t offer much help as there are no instructional notes listed with the subcategory other than the list of seventh character options to use.

But, as the Orthopedic Coding Alert reports, the March 2012 Summary of Diagnosis Presentations from the Coordination and Maintenance Committee provides a clue about what these orthopedic ICD-10 codes refer to.

The Summary reveals that “atypical fracture” is a term that’s common in academic settings, but it may be less common outside of academics. You may see these types of femur fractures referred to as Fosamax fractures, but they can occur in patients who haven’t taken bisphosphonates. The radiology report may help in identifying these fractures as they have characteristic radiographic findings such as thickened cortices (outer layers).

2. Demand Cervical Disc in Documentation

If you code for cervical disc disorders, don’t miss the change from codes that lumped “mid-cervical region” codes together. Under ICD-10 2017, you’ll need to know whether the condition affects C4-C5, C5-C6, or C6-C7 (check your M50.-2- codes for 2017).

Example: ICD-10 2016 code M50.22 (Other cervical disc displacement, mid-cervical region) will expand in ICD-10 2017 to these four codes:

  • M50.220, Other cervical disc displacement, mid-cervical region, unspecified level
  • M50.221, Other cervical disc displacement at C4-C5 level
  • M50.222, Other cervical disc displacement at C5-C6 level
  • M50.223, Other cervical disc displacement at C6-C7 level.

3. Remember to Look Beyond the Codes

Code additions get a lot of attention, but they aren’t the only changes that can affect your coding accuracy and documentation needs. You have to review additions, revisions, and deletions to the Tabular notes and Index, too.

You may find a note that gives you confidence you’re using the correct code for a diagnosis, such as the addition of “compression fracture of vertebra NOS” with M48.5- (Collapsed vertebra, not elsewhere classified).

Or you may discover code changes you might have missed otherwise, like the change in the seventh character requirements for S99.- (Other and unspecified injuries of ankle and foot). Instead of using A (initial), D (subsequent), and S (sequela) for each code in that category, check the subcategory’s requirements.

Example: A note with new subcategory S99.0- (Physeal fracture of calcaneus) lists these seventh character options:

  • A, Initial encounter for closed fracture
  • B, Initial encounter for open fracture
  • D, Subsequent encounter for fracture with routine healing
  • G, Subsequent encounter for fracture with delayed healing
  • K, Subsequent encounter for fracture with nonunion
  • P, Subsequent encounter for fracture with malunion
  • S, Sequela.

What About You?

Are you feeling frustrated by ICD-10 changes, or are you seeing some new options that you think will be helpful?

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Part 2: 17 Changes Coming Your Way in CPT® 2017

Mon, Aug 15, 2016

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2017 CPT changes

In Part 1, SuperCoder blog covered six areas expecting changes under CPT® 2017. Get ready to explore lucky numbers 7 to 17.

Remember: This summary is based on a preliminary list of expected changes. The code set is not final yet, so there could be adjustments before you start applying the codes on Jan. 1, 2017.

Let’s get back to the expected updates!

7. Watch Imaging Guidance for 62310-62319 Replacements

If all goes as planned, you’ll be swapping out your old spinal injection codes 62310-62319 for new codes that allow you to distinguish which services the provider performed using imaging guidance.

8. Add New AAA Screening and Mammography Options for Radiology

AAA: All you coders who’ve been asking which CPT® code to use for abdominal aortic aneurysm screening by ultrasound, rejoice! CPT® 2017 will be adding that new AAA screening code at long last, providing clarity if you’re reporting to a payer who doesn’t accept the HCPCS option.

Mammo: Mammography codes are changing with the times and including computer-aided detection when performed.

9. Plan Now for Path/Lab Changes

Drug tests: Prepare to pack up and ship out old drug screen codes 80300-80304. You’ll have some new presumptive drug test codes to learn, too.

Molecular pathology: You’ll see some changes affecting MoPath levels 2, 4, and 7.

Genomic sequencing/MAAA: CPT® 2017 also dishes up new codes related to cardiac, fetal, and prostate cancer testing.

More! CPT® has a few changes in store for Chemistry and Microbiology codes, too. Be sure you get expert analysis to understand the changes for this unique specialty.

10. Dig Into Dosage for Flu Vax Codes

Many of your old familiar 906xx flu vaccine code descriptors will get a new look, swapping out the age of the patient for a new focus on dosage amount to dictate your code choice.

11. See How Revisions Affect Psychotherapy Coding

Psychotherapy coders should watch for a change removing “and/or family” from codes 90832-90838. Family psychotherapy codes 90846 and 90847 will see the addition of 50 minute time criteria in their descriptors.

12. Capture 1 Eye or 2 With Angiography Update

Eye coders will need to watch changes for fluorescein angiography code 92235 and indocyanine-green angiography code 92240. CPT® 2017 revises these codes to specify that they apply whether the service is unilateral or bilateral. Plus there will be a new code option for when the patient has both services at the same encounter.

13. Expect More Cardiovascular Changes in Medicine Section

IVUS: Coronary intravascular ultrasound (IVUS) codes 92978 and 92979 will now also apply to optical coherence tomography (OCT). In 2016, you use a Cat. III code for OCT.

Valve: Watch for new options for reporting percutaneous occlusion of mitral and aortic valve leaks.

Vein study: It appears noninvasive vein study code 93965 will bow out, deleted for 2017.

14. Anticipate 2 New Health Assessment Choices

You’ll have two new codes available for administering health risk assessment instruments. Choose between them based on whether the patient or caregiver supplies answers.

15. Know What’s New for Injectors

CPT® 2017 includes a new code for applying an on-body injector (subcutaneous) for a patient.

16. Prepare for Therapy Eval Makeover

Therapy coders will have fresh options for evaluation and reevaluation related to physical therapy, occupational therapy, and athletic training. The codes vary by complexity, and the descriptors are structured in a way that’s similar to E/M codes.

17. Last But Not Least — Larval Therapy

With the addition of “larval therapy” to the list of examples in debridement code 97602, you can be sure you’ve got the right code when documentation shows application of medical-grade, live maggots to wounds.

What Do You Think?

Which changes look the most helpful? Are you eager to see the guidelines that go along with any of these new codes?

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Part 1: 17 Changes Coming Your Way in CPT® 2017

Fri, Aug 12, 2016


CPT 2017 update

A look at the CPT® 2017 pre-production file reveals that if you can get a grip on conscious sedation changes, you’ll master a massive chunk of the updates in one fell swoop. But the devil is in the details, as the saying goes. This rundown of the expected changes will help you decide where to focus the preparations for your specialty.

In Part 1, you’ll see numbers 1 to 6, taking you from conscious sedation to uterine fibroid ablation. Check back in for Part 2 in the next post, which will range from spinal injections to larval therapy!

Keep in mind: This overview is based on the not-yet-final list of CPT® updates, so there could be changes before the code set becomes final and before you start using the codes for dates of service Jan. 1, 2017, and later. This summary highlights changes from the Category I updates.

1. Clue In to the Conscious Sedation Revolution

Expect CPT® 2017 to remove the conscious sedation symbol from the more than 400 codes that currently carry the mark. That mark meant that you should not report moderate/conscious sedation in addition to the procedure code. You also can anticipate the deletion of the current moderate sedation codes. You’ll replace the old codes with new ones that apply in 15-minute increments instead of the 30 minutes used in the 2016 codes.

Tip: Gastroenterology coders should check out this American Gastroenterological Association document discussing the changes and the likely implementation of a HCPCS code specific to gastrointestinal endoscopic services (excluding biliary procedures) to reflect the work and costs specific to that specialty.

The document also explains that the changes are occurring because CMS has seen an increase in anesthesia billed separately from endoscopic procedures. That meant the resource cost for conscious sedation was included in the surgical code reimbursement, but the surgeon wasn’t incurring that cost.

2.  Break Old Bone Coding Habits

Spine: Spine coders should prepare to replace biomechanical device insertion code 22851 with new code options. Watch for three new add-on codes for biomechanical device insertion, plus four more new codes related to stabilization device insertion.

Pelvic ring: If you code for pelvic ring fractures, expect to see a couple of new options for closed treatment.

Bunion: Foot surgery coders will have changes to their bunion CPT® codes to learn along with the new ICD-10 2017 codes M21.61- (Bunion) and M21.62- (Bunionette). Unlike ICD-10, CPT® doesn’t seem to mind keeping hallux valgus and bunion in the same code.

3. Forget Fiberoptic, Add Age for Larynx Services

Coding for larynx procedures will look a little different in 2017, with “fiberoptic” removed from laryngoscopy codes and the addition of new laryngoplasty codes, including stenosis codes that differ based on patient age.

4. Make Room for Multiple Cardiovascular Surgery Changes

Heart: Percutaneous left atrial appendage closure (LAAC) will move from Cat. III to Cat. I. And you’ll have two new options for open aortic valvuloplasty.

Angioplasty: Plan to move your search for visceral, aortic, brachiocephalic, and venous balloon angioplasty to new code options that lump open and percutaneous procedures together. The new codes include radiological supervision and interpretation, so expect to say so long to the related radiology codes.

Dialysis circuit: The 2017 code set plans to delete dialysis AV shunt imaging and intervention codes 36147 and 36148, but you’ll have nine new codes specific to dialysis vascular services.

Newborn transfusion: Watch for a new code specific to partial exchange transfusion in a newborn. You’ll use the code when the procedure requires expert skill.

Endovenous ablation: You’ll see some changes to endovenous ablation codes, most notably new options for mechanochemical ablation.

Tip: See number 13 in Part 2 for cardiovascular medicine section changes.

5. Don’t Miss Esophageal Sphincter Augmentation Additions

If you’ve been hoping for new code options for esophageal sphincter augmentation device placement and removal, CPT® 2017 answers your wish with a new code for each.

6. See Cat. I for Uterine Fibroid Ablation in 2017

Laparoscopic uterine fibroid ablation got the vote of approval and moved from Cat. III to Cat. I.

How About You?

Which changes are you interested in learning more about?

See you soon for Part 2 of the CPT® 2017 overview!

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$300 Billion: CMS Cardiac Bundle by the Numbers

Tue, Aug 9, 2016


CMS cardiac bundled payments


CMS wants better care at a lower cost. That doesn’t sound like the easiest task, but they’ve offered a game plan for cardiac care that shows how one could lead to the other.

The idea is that if hospitals work together with physicians and other providers (like SNFs), then the result will be heart attack and bypass patients experiencing fewer costly complications, lower rates of hospital readmission, and faster recovery times, too.

The proposed models include a new CMS bundled payment system for cardiac care, a new way to increase use of cardiac rehabilitation programs, and — not to be missed — payment incentives for “physicians with significant participation in bundled payment models.”

Catch the Key Numbers for Cardiac Bundled Payments

$300 billion is the annual health care cost for heart attacks and strokes.

30 percent of Medicare payments go through alternative models.

50 percent is the 2018 goal for having traditional Medicare payments going through alternative payment models.

98 randomly-selected metropolitan statistical areas hold the hospitals participating in this Medicare bundled payments model for cardiac services.

5 model years are planned for the phased implementation from July 2017 to 2021.

Inpatient stay + 90 days after discharge is the time that the admitting hospital will be accountable for cost and quality of care provided to Medicare fee-for-service beneficiaries.

1.5 to 3 percent discount rates will apply to an individual hospital’s quality-adjusted target price with the lowest discount applying to those providing the highest-quality care. Confused? See the next two numbers for examples.

$1,250 will be the average per patient savings paid to a hospital in this example from CMS: A hospital in model year 4 is in an area where Medicare spends an average of $50,000 for each patient undergoing coronary bypass (surgery plus care for 90 days after discharge). The hospital has a discount rate of 1.5 percent, so its target price is $49,250, which is $50,000 minus the 1.5 percent discount. The hospital takes steps to keep down readmissions and averages $48,000 in costs. Medicare will pay the hospital the difference between the target price and the average costs, so the hospital gets a savings payment of $1,250 per patient.

$1,500 is the per patient amount a hospital will have to pay back to Medicare in this CMS example: A hospital in model year 4 is in an area where Medicare spends an average of $50,000 for each patient undergoing coronary bypass (surgery plus care for 90 days after discharge). The hospital has a discount rate of 3 percent, so its target price is $48,500, which is $50,000 minus the 3 percent discount. The hospital hasn’t succeeded in improving cost and quality performance and averages $50,000 in costs. Medicare will require the hospital to pay the difference between the target price and the average costs, so the hospital will owe an average of $1,500 per patient.

45 geographic areas not in the cardiac care bundled payment models and 45 other areas that are in the bundled payment models are involved in the cardiac rehabilitation incentive payment model.

2 parts are in the cardiac rehabilitation incentive payment, paid retrospectively:

  • $25 initial payment for cardiac rehab for each of the first 11 services Medicare pays during the heart attack or bypass care period
  • $175 payment per service after the initial 11.

2 one-hour cardiac rehab sessions per day for up to 36 sessions over 36 weeks is the max unless the MAC approves an additional 36 sessions.

6 one-hour sessions per day for up to 72 sessions over 18 weeks is the max for intensive cardiac rehab.

2018 is the year physicians could see financial rewards through the Quality Payment Program for participating in these models.

How About You?

Are you a fan of the move to payment based on quality of care? Do you see foresee any issues or have suggestions how to improve payment models?

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2017 MPFS Proposed Rule: Which Changes Are in the Spotlight?

Fri, Aug 5, 2016

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Primary care and diabetes prevention — Those are the buzz words flying around CMS’s proposed changes to the Physician Fee Schedule for 2017. Here’s a snapshot of the proposed rule.

CMS Changes Fee Schedule to Promote Primary Care

According to a CMS announcement, one step the agency is taking to recognize primary care work for Medicare beneficiaries is to provide separate payment for care management and cognitive work instead of bundling payment for that work into E/M codes. The goal is to be sure payment for the services reaches the providers actually performing the work.

Proposals include separate payments for the following:

  • Existing non-face-to-face prolonged E/M services (and new values for existing face-to-face prolonged E/M services)
  • New assessment and care planning codes for patients with dementia or other cognitive impairments
  • New interprofessional care management codes for patients with behavioral health conditions
  • New codes for resource costs related to treating patients with mobility-related impairments
  • Codes for complex chronic care management (and a reduction in red tape, too).

Diabetes Prevention Program May See Medicare Expansion

Acccepting the truth of the old adage that an ounce of prevention is worth a pound of cure, CMS has proposed to expand the Diabetes Prevention Program into Medicare. This would begin Jan. 1, 2018, with the time in between used to work on details such as how to enroll program organizations in Medicare, payment structure, and claims submission, as well as defining eligible pre-diabetic patients.

The program combines 16 intensive classroom-style sessions on nutrition, physical activity, and behavior changes followed by monthly check-ins to help with maintenance.

The Proposed Rule Packs In Even More Changes, Of Course

Some of the other payment provision areas CMS is emphasizing in the proposed rule include the following:

  • Misvalued services: Remember how the conversion factor got dropped in 2016 in part because of misvalued services calculations? CMS indicates the 2017 rule should avoid that issue by meeting the misvalued code changes goal for the year.
  • Moderate sedation: The proposed rule discusses values for moderate sedation codes and the need to get a handle on sedation patterns for endoscopy.
  • Telehealth: CMS may add certain ESRD dialysis, advanced care planning, and Medicare G code critical care services to the list of telehealth eligible services. We may see a new place of service code for telehealth, too.
  • Mammograms: In the future, we may see new codes for mammography to better reflect current use of digital imaging and computer-aided detection.
  • GPCI: Expect to see some changes to the Geographic Practice Cost Indices, including potential payment increases in Puerto Rico and urban California.
  • Global surgical package: In addition to including a data collection strategy to value post-surgical services (to better inform the debate about transforming all 10- and 90-day global codes to 0-day), the proposed rule lists 83 services with 0-day globals to review. The reason given for the latter is that a large number of claims report an E/M along with those 83 services despite the global-day restrictions.

Act now: CMS is accepting comments until Sept. 6, 2016, for the proposed rule.

How About You?

Were you surprised by anything in the proposed Medicare Physician Fee Schedule 2017? Is there anything you hope won’t make it into the final rule? Or are you most concerned with what ends up in the CMS Physician Fee Schedule lookup?

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Before & After: 3 Ways Your GI ICD-10 Coding Will Change Oct. 1

Tue, Aug 2, 2016


gastroenterology ICD10 2017

During the ICD-10 transition, two characteristics that got a lot of attention were ICD-10’s detailed codes and the new code set’s room for expansion. The ICD-10 2017 updates released by the CDC and CMS reveal that the two characteristics go hand in hand: more room to expand means more room to add specificity requirements.

Here’s how that change will play out for gastroenterology ICD-10 coders when the 2017 codes become effective for dates of service Oct. 1, 2016, and later.

1. Move Stromal Tumor Search to C49.A-

Before: In ICD-10-CM 2016, the Index entry for Tumor, Stromal, Gastrointestinal, Malignant points you to C49.4 (Malignant neoplasm of connective and soft tissue of abdomen). The Stomach entry points you to C16.9 (Malignant neoplasm of stomach, unspecified).

After: Starting with Oct. 1 DOS, you’ll have more specific options for malignant stromal GI tumors based on site:

  • C49.A0, Gastrointestinal stromal tumor, unspecified site
  • C49.A1, … esophagus
  • C49.A2, … stomach
  • C49.A3, … small intestine
  • C49.A4, … large intestine
  • C49.A5, … rectum
  • C49.A9, … other sites.

2. Include These IBS Additions in CDI Training

Before: You’re no doubt familiar with ICD-10 2016’s options for IBS:

  • K58.0, Irritable bowel syndrome with diarrhea
  • K58.9, Irritable bowel syndrome without diarrhea.

After: ICD-10 2017 keeps K58.0 and K58.9, but it also will add three new options:

  • K58.1, Irritable bowel syndrome with constipation
  • K58.2, Mixed irritable bowel syndrome
  • K58.8, Other irritable bowel syndrome.

Tip: Coders in the field report that documentation in the real-world may offer no more details than “IBS.” Be sure to share the new codes with providers so they know the sort of detail ICD-10 includes. But if the medical records you see continue to state only IBS, keep in mind that in both the 2016 and 2017 ICD-10 code sets, K58.9 is appropriate for IBS NOS.

3. Know Necrosis and Infection Status for Pancreatitis

Before: ICD-10 2016 gives you six codes to choose from for acute pancreatitis in the range K85.0-K85.9.

After: ICD-10 2017 multiples your choices by three. Each of the existing four-character 2016 ICD-10 pancreatitis codes will require a fifth character under ICD-10 2017:

  • 0, … without necrosis or infection
  • 1., …with uninfected necrosis
  • 2, … with infected necrosis.

How About You?

How is your practice preparing for gastroenterology ICD-10-CM changes for 2017? Are you following the same process that you used for ICD-9 updates or does ICD-10 require a different approach?

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Stay Sharp! Here’s Why ‘ICD-10 Specificity Fatigue’ Can Get You in Trouble

Fri, Jul 29, 2016


After years on the ICD-10 prep treadmill, your mind may go numb when you hear “ICD-10 specificity requirements” repeated for the millionth time.

Wake up call: CMS has a couple of upcoming changes that will add some new energy to your clinical documentation improvement and ICD-10 code choice efforts.

Oct. 1: Denials May Increase When Grace Period Ends

The change you’re probably hearing the most about is the end of CMS’s so-called grace period, which prevents denials based on ICD-10 as long as your code is in the right code family (category).

The grace period was designed to last for one year after the Oct. 1, 2015, ICD-10 implementation, leaving us with just a couple more months to go.

Presumably, you’ve been doing your best to choose the most specific code regardless of the grace period’s flexibility. Even so, it’s time to recognize that the stakes will be raised (increased chance of denials) and to be sure you’re ready to select the most accurate ICD-10 2017 codes starting with Oct. 1, 2016, dates of service.

2017 tip 1: Review the ICD-10 2017 code changes to catch increased specificity requirements. For instance, lots of diabetes codes that include eye manifestations will have new characters added requiring you to identify the eye(s) involved.

ICD10 2017 codes

2017 tip 2: Be sure your ICD-10-CM resource carries codes out to the final required character. Some sources may mention the requirement for a seventh character only as a note at a higher level.

One example is the group of new urinary catheter complication codes. Each requires a seventh character, but the CDC’s ICD-10 2017 Tabular PDF makes this tough to see, listing the instruction only at the category (three-character) level. You’ll spend a lot of time checking instructions or dealing with denials if you choose a resource that doesn’t make it easy to see which codes are complete and reportable.

Jan. 2: Workers’ Comp, No-Fault, or Liability? Check Excluded Codes Update

Another change you should be aware of is CMS’s update to the list of excluded ICD-10-CM codes that relate to MMSEA Section 111, Medicare Secondary Payer Mandatory Reporting, Liability Insurance (Including Self-Insurance), No-Fault Insurance, and Workers’ Compensation. This change is effective Jan. 2, 2017.

A Technical Alert from CMS reveals the addition of nine codes to the list of excluded ICD-10-CM diagnosis codes. These include the following subcategories:

  • T88.7XX-, Unspecified adverse effect of drug or medicament
  • T88.8XX-, Other specified complications of surgical and medical care, not elsewhere classified
  • T88.9XX-, Complication of surgical and medical care, unspecified.

Denial prevention: If you deal with certain types of adverse effects and complications regularly, you can offer the provider a list of the codes most relevant to your practice to show the sort of information you need for coding.

How About You?

Are you worried about the first ICD-10 update? Do you have any advice on how to ensure documentation supports choosing the most specific code?


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3 Ways to Torpedo Your Medicare Smoking Cessation Claims

Tue, Jul 26, 2016


coding smoking cessation counseling

There seems to be an uptick in interest in how to report smoking cessation counseling recently. Whether your practice is combining this service with low dose CT lung cancer screening or simply putting renewed energy into educating patients about healthy options, your task is to code the claim correctly. Watch out for these three common missteps.

1. Not Choosing the Correct Counseling Codes

Before you choose the counseling code, you need to ask yourself two questions:

  • Did the patient have symptoms associated with tobacco use?
  • How long did the counseling encounter last?

This table demonstrates how your smoking cessation counseling HCPCS and CPT® choices line up depending on your answers.

Cessation Counseling >3 min. up to 10 min. >10 min.
Asymptomatic G0436 G0437
Symptomatic 99406 99407

Diagnosis: Be sure to link the counseling to an appropriate diagnosis code, such as an approved option from F17.2- (Nicotine dependence).

2. Not Checking Every Last Patient Requirement

To be eligible, the Medicare beneficiary must use tobacco, be competent and alert for counseling, and have the counseling from a qualified physician or other practitioner that Medicare recognizes for the service.

Additionally, you need to count both the number of attempts and the number of sessions in each attempt. Medicare covers two attempts within a year. Each attempt includes no more than four sessions.

3. Not Defining Documentation Must-Haves

Checking patient requirements will be a lot easier if you’ve worked with the clinical team to define the precise documentation you need to support reporting these smoking cessation counseling services.

The American Academy of Family Physicians (AAFP) provides a helpful EHR template here.

The gist: The provider wants to be sure to document talking to the patient about tobacco use over the previous 12 months and recommending that the patient stop tobacco use. Documentation should include whether the patient is interested in quitting and the advice the provider offered on achieving that goal. The record should also show that a follow-up appointment is scheduled in four to six weeks.

What About You?

Have you found a good system for ensuring you meet the requirements for coding smoking cessation counseling?

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